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Sin Y, Batumalai V, de Leon J, Leong E, Rahim K, Kasraei F, Tran C, Liang T, Biggerstaff K, Jameson MG, Hug N, Hird K, Tan H. Does a peer review group consensus process for MR-Linac patients affect clinical care? Evaluation of impact and feasibility. Clin Transl Radiat Oncol 2024; 48:100816. [PMID: 39130107 PMCID: PMC11315065 DOI: 10.1016/j.ctro.2024.100816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 08/13/2024] Open
Abstract
Background and purpose Peer review is an important component of quality assurance in radiotherapy. To our knowledge, there are no studies reporting on the feasibility and outcomes of the peer review process for magnetic resonance (MR) guided radiotherapy (MRgRT) on the MR linear accelerator (MR-Linac) despite the planning complexity involved and its evolving clinical indications. This study aimed to quantify the rate of change in treatment plans post-peer review and the time and resources required. Materials and methods Fifty-five cases presented at weekly MR-Linac peer review meetings across two centres from 8 June to 21 September 2023 were prospectively collected. Cases were analysed to determine the rate and extent of plan changes based on the Peer Review Audit Tool for radiation oncology (PRAT) developed by the Royal Australian and New Zealand College of Radiologists (RANZCR). Results Peer review resulted in changes to 36.4 % of treatment plans (n = 20), with 3.6 % (n = 2) having major changes requiring deferment of treatment. The most frequent changes were to organs at risk (OAR) volumes involving both delineation and increased OAR sparing (16.4 %, n = 9), total dose and fractionation (10.9 %, n = 6) and target volume dose coverage (5.5 %, n = 3). Patients with SBRT plans (39.1 % cf 22.2 %), oligometastatic/oligoprogressive sites (38.1 % cf 30.7 %) and reirradiation cases (41.2 % cf 34.2 %) had higher rates of change. Cases took a mean of 7 min (range 2-15 minutes) to discuss. Conclusion The high rates of plan changes support the value of peer review in MRgRT. We recommend, where possible that all MRgRT cases, particularly those involving SBRT plans, oligometastatic/oligoprogressive sites, and/or reirradiation, be subject to peer review.
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Affiliation(s)
- Yew Sin
- University of Notre Dame Australia, School of Medicine, Fremantle, Western Australia, Australia
| | - Vikneswary Batumalai
- GenesisCare, St Vincent’s Hospital, New South Wales, Australia
- The George Institute for Global Health, Faculty of Medicine and Health, UNSW Sydney, New South Wales, Australia
| | - Jeremy de Leon
- GenesisCare, St Vincent’s Hospital, New South Wales, Australia
| | - Eugene Leong
- GenesisCare, Murdoch, Western Australia, Australia
- Fiona Stanley Hospital, Department of Radiation Oncology, Murdoch, Western Australia, Australia
| | - Kasri Rahim
- GenesisCare, Murdoch, Western Australia, Australia
- Fiona Stanley Hospital, Department of Radiation Oncology, Murdoch, Western Australia, Australia
| | - Farshad Kasraei
- GenesisCare, St Vincent’s Hospital, New South Wales, Australia
| | - Charles Tran
- GenesisCare, St Vincent’s Hospital, New South Wales, Australia
| | - Tommy Liang
- GenesisCare, Murdoch, Western Australia, Australia
| | | | - Michael G. Jameson
- GenesisCare, St Vincent’s Hospital, New South Wales, Australia
- The University of New South Wales, Sydney, Australia
| | - Nicole Hug
- GenesisCare, Murdoch, Western Australia, Australia
| | - Kathryn Hird
- University of Notre Dame Australia, School of Medicine, Fremantle, Western Australia, Australia
| | - Hendrick Tan
- GenesisCare, Murdoch, Western Australia, Australia
- Fiona Stanley Hospital, Department of Radiation Oncology, Murdoch, Western Australia, Australia
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Poiset SJ, Shah S, Cappelli L, Anné P, Mooney KE, Werner-Wasik M, Laufer TS, Posey JA, Lin D, Basu Mallick A, Lavu H, Bashir B, Yeo CJ, Mueller AC. Early outcomes of MR-guided SBRT for patients with recurrent pancreatic adenocarcinoma. Radiat Oncol 2024; 19:65. [PMID: 38812040 PMCID: PMC11138072 DOI: 10.1186/s13014-024-02457-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/17/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Local treatment options for locally recurrent pancreatic adenocarcinoma (LR-PAC) are limited, with median survival time (MST) of 9-13 months (mos) following recurrence. MRI-guided stereotactic body radiation therapy (MRgSBRT) provides the ability to dose escalate while sparing normal tissue. Here we report on the early outcomes of MRgSBRT for LR-PAC. METHODS Patients with prior resection of pancreatic adenocarcinoma with local recurrence treated with MRgSBRT at a single tertiary referral center from 5-2021 to 2-2023 were identified from our prospective database. MRgSBRT was delivered to 40-50 Gy in 4-5 fractions with target and OAR delineation per institutional standards. Endpoints included local control per RECIST v1.1, distant failure, overall survival (OS), and acute and chronic toxicities per Common Terminology Criteria for Adverse Events, v5. RESULTS Fifteen patients with LR-PAC were identified with median follow-up of 10.6 mos (2.8-26.5 mos) from MRgSBRT. There were 8 females and 7 males, with a median age of 69 years (50-83). One patient underwent neoadjuvant radiation for 50.4 Gy in 28 fractions followed by resection, and one underwent adjuvant radiation for 45 Gy in 25 fractions prior to recurrence. MRgSBRT was delivered a median of 18.8 mos (3.5-52.8 mos) following resection. OS following recurrence at 6 and 12 mos were 87% and 51%, respectively, with a median survival time of 14.1 mos (3.2-27.4 mos). Three patients experienced local failure at 5.9, 7.8, and 16.6 months from MgSBRT with local control of 92.3% and 83.9% at 6 and 12 months. 10 patients experienced distant failure at a median of 2.9 mos (0.3-6.7 mos). Grade 1-2 acute GI toxicity was noted in 47% of patients, and chronic GI toxicity in 31% of patients. No grade > 3 toxicities were noted. CONCLUSIONS This is the first report on toxicity and outcomes of MRgSBRT for LR-PAC in the literature. MRgSBRT is a safe, feasible treatment modality with the potential for improved local control in this vulnerable population. Future research is necessary to better identify which patients yield the most benefit from MRgSBRT, which should continue to be used with systemic therapy as tolerated. TRIAL REGISTRATION Jefferson IRB#20976, approved 2/17/21.
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Affiliation(s)
- Spencer J Poiset
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Sophia Shah
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Louis Cappelli
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Pramila Anné
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Karen E Mooney
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Maria Werner-Wasik
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Talya S Laufer
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - James A Posey
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel Lin
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Atrayee Basu Mallick
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Harish Lavu
- Department of Surgery, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Babar Bashir
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Charles J Yeo
- Department of Surgery, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam C Mueller
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA.
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA.
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3
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Dee EC, Ng VC, O’Reilly EM, Wei AC, Lobaugh SM, Varghese AM, Zinovoy M, Romesser PB, Wu AJ, Hajj C, Cuaron JJ, Khalil DN, Park W, Yu KH, Zhang Z, Drebin JA, Jarnagin WR, Crane CH, Reyngold M. Salvage Ablative Radiotherapy for Isolated Local Recurrence of Pancreatic Adenocarcinoma following Definitive Surgery. J Clin Med 2024; 13:2631. [PMID: 38731159 PMCID: PMC11084663 DOI: 10.3390/jcm13092631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Introduction: The rate of isolated locoregional recurrence after surgery for pancreatic adenocarcinoma (PDAC) approaches 25%. Ablative radiation therapy (A-RT) has improved outcomes for locally advanced disease in the primary setting. We sought to evaluate the outcomes of salvage A-RT for isolated locoregional recurrence and examine the relationship between subsequent patterns of failure, radiation dose, and treatment volume. Methods: We conducted a retrospective analysis of all consecutive participants who underwent A-RT for an isolated locoregional recurrence of PDAC after prior surgery at our institution between 2016 and 2021. Treatment consisted of ablative dose (BED10 98-100 Gy) to the gross disease with an additional prophylactic low dose (BED10 < 50 Gy), with the elective volume covering a 1.5 cm isotropic expansion around the gross disease and the circumference of the involved vessels. Local and locoregional failure (LF and LRF, respectively) estimated by the cumulative incidence function with competing risks, distant metastasis-free and overall survival (DMFS and OS, respectively) estimated by the Kaplan-Meier method, and toxicities scored by CTCAE v5.0 are reported. Location of recurrence was mapped to the dose region on the initial radiation plan. Results: Among 65 participants (of whom two had two A-RT courses), the median age was 67 (range 37-87) years, 36 (55%) were male, and 53 (82%) had undergone pancreaticoduodenectomy with a median disease-free interval to locoregional recurrence of 16 (range, 6-71) months. Twenty-seven participants (42%) received chemotherapy prior to A-RT. With a median follow-up of 35 months (95%CI, 26-56 months) from diagnosis of recurrence, 24-month OS and DMFS were 57% (95%CI, 46-72%) and 22% (95%CI, 14-37%), respectively, while 24-month cumulative incidence of in-field LF and total LRF were 28% (95%CI, 17-40%) and 36% (95%CI 24-48%), respectively. First failure after A-RT was distant in 35 patients (53.8%), locoregional in 12 patients (18.5%), and synchronous distant and locoregional in 10 patients (15.4%). Most locoregional failures occurred in elective low-dose volumes. Acute and chronic grade 3-4 toxicities were noted in 1 (1.5%) and 5 patients (7.5%), respectively. Conclusions: Salvage A-RT achieves favorable OS and local control outcomes in participants with an isolated locoregional recurrence of PDAC after surgical resection. Consideration should be given to extending high-dose fields to include adjacent segments of at-risk vessels beyond direct contact with the gross disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Marsha Reyngold
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (E.C.D.); (V.C.N.); (C.H.C.)
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Shouman MA, Fuchs F, Walter F, Corradini S, Westphalen CB, Vornhülz M, Beyer G, Andrade D, Belka C, Niyazi M, Rogowski P. Stereotactic body radiotherapy for pancreatic cancer - A systematic review of prospective data. Clin Transl Radiat Oncol 2024; 45:100738. [PMID: 38370495 PMCID: PMC10873666 DOI: 10.1016/j.ctro.2024.100738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/05/2024] [Accepted: 01/26/2024] [Indexed: 02/20/2024] Open
Abstract
Purpose This systematic review aims to comprehensively summarize the current prospective evidence regarding Stereotactic Body Radiotherapy (SBRT) in various clinical contexts for pancreatic cancer including its use as neoadjuvant therapy for borderline resectable pancreatic cancer (BRPC), induction therapy for locally advanced pancreatic cancer (LAPC), salvage therapy for isolated local recurrence (ILR), adjuvant therapy after radical resection, and as a palliative treatment. Special attention is given to the application of magnetic resonance-guided radiotherapy (MRgRT). Methods Following PRISMA guidelines, a systematic review of the Medline database via PubMed was conducted focusing on prospective studies published within the past decade. Data were extracted concerning study characteristics, outcome measures, toxicity profiles, SBRT dosage and fractionation regimens, as well as additional systemic therapies. Results and conclusion 31 studies with in total 1,571 patients were included in this review encompassing 14 studies for LAPC, 9 for neoadjuvant treatment, 2 for adjuvant treatment, 2 for ILR, with an additional 4 studies evaluating MRgRT. In LAPC, SBRT demonstrates encouraging results, characterized by favorable local control rates. Several studies even report conversion to resectable disease with substantial resection rates reaching 39%. The adoption of MRgRT may provide a solution to the challenge to deliver ablative doses while minimizing severe toxicities. In BRPC, select prospective studies combining preoperative ablative-dose SBRT with modern induction systemic therapies have achieved remarkable resection rates of up to 80%. MRgRT also holds potential in this context. Adjuvant SBRT does not appear to confer relevant advantages over chemotherapy. While prospective data for SBRT in ILR and for palliative pain relief are limited, they corroborate positive findings from retrospective studies.
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Affiliation(s)
- Mohamed A Shouman
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Frederik Fuchs
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - Franziska Walter
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - C Benedikt Westphalen
- Department of Medicine III and Comprehensive Cancer Center (CCC Munich LMU), University Hospital LMU, Munich, Germany
| | - Marlies Vornhülz
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Georg Beyer
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Dorian Andrade
- Department of General, Visceral, and Transplant Surgery, University Hospital LMU, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Germany
| | - Paul Rogowski
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
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5
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Lautenschlaeger S, Dumke C, Exeli L, Hauswald H, Engenhart-Cabillic R, Eberle F. Treatment of primary or recurrent non-resectable pancreatic cancer with proton beam irradiation combined with gemcitabine-based chemotherapy. Strahlenther Onkol 2023; 199:982-991. [PMID: 37428207 DOI: 10.1007/s00066-023-02106-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/04/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Pancreatic cancer accounts for around 4.6% of cancers deaths worldwide per year. Despite many advances in treatment regimes, the prognosis is still poor. Only 20% of tumors are primarily resectable. Recurrences-both with distant metastasis as well as locoregional-are frequent. For patients with primary nonresectable localized disease or localized recurrences, we offered chemoradiation to achieve local control over a long period of time. We here report our results on combined chemoradiation of pancreatic tumors and local recurrences using proton beam therapy. MATERIALS AND METHODS We report on 25 patients with localized nonresectable pancreatic cancer (15 patients) or local recurrent disease (10 patients). All patients were treated with combined proton radiochemotherapy. Overall survival, progression-free survival, local control, and treatment-related toxicity were analyzed using statistically methods. RESULTS Median RT dose was 54.0 Gy (RBE) for proton irradiation. The toxicity of treatment was acceptable. Four CTCAE grade III and IV adverse events (bone marrow disfunction, gastrointestinal [GI] disorders, stent dislocation, myocardial infarction) were recorded during or directly after the end of radiotherapy; two of them were related to combined chemoradiation (bone marrow disfunction, GI disorders). Six weeks after radiotherapy, one additional grade IV toxicity was reported (ileus, caused by peritoneal carcinomatosis, not treatment related). The median progression-free survival was 5.9 months and median overall survival was 11.0 months. The pretherapy CA19‑9 level was a statistically significant prognostic factor for enhanced overall survival. Local control at 6 months and 12 months were determined to be 86% and 80%, respectively. CONCLUSION Combined proton chemoradiation leads to high local control rates. Unfortunately, PFS and OS are driven by distant metastasis and were not improved compared to historical data and reports. With this in mind, enhanced chemotherapeutical regimes, in combination with local irradiation, should be evaluated.
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Affiliation(s)
- S Lautenschlaeger
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany.
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany.
| | - C Dumke
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - L Exeli
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - H Hauswald
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
- RNS Gemeinschaftspraxis, St. Josefs-Hospital, Wiesbaden, Germany
- Klinik für Radio-Onkologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - R Engenhart-Cabillic
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - F Eberle
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Marburg, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
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6
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Cao Y, Zhu X, Yu C, Jiang L, Sun Y, Guo X, Zhang H. Dose evaluations of organs at risk and predictions of gastrointestinal toxicity after re-irradiation with stereotactic body radiation therapy for pancreatic cancer by deformable image registration. Front Oncol 2023; 12:1021058. [PMID: 36793343 PMCID: PMC9923872 DOI: 10.3389/fonc.2022.1021058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/07/2022] [Indexed: 01/31/2023] Open
Abstract
Purpose Re-irradiation of locally recurrent pancreatic cancer may be an optimal choice as a local ablative therapy. However, dose constraints of organs at risk (OARs) predictive of severe toxicity remain unknown. Therefore, we aim to calculate and identify accumulated dose distributions of OARs correlating with severe adverse effects and determine possible dose constraints regarding re-irradiation. Methods Patients receiving two courses of stereotactic body radiation therapy (SBRT) for the same irradiated regions (the primary tumors) due to local recurrence were included. All doses of the first and second plans were recalculated to an equivalent dose of 2 Gy per fraction (EQD2). Deformable image registration with the workflow "Dose Accumulation-Deformable" of the MIM® System (version: 6.6.8) was performed for dose summations. Dose-volume parameters predictive of grade 2 or more toxicities were identified, and the receiver operating characteristic (ROC) curve was used to determine optimal thresholds of dose constraints. Results Forty patients were included in the analysis. Only the V 10 of the stomach [hazard ratio (HR): 1.02 (95% CI:1.00-1.04), P = 0.035] and D mean of the intestine [HR: 1.78 (95% CI: 1.00-3.18), P = 0.049] correlated with grade 2 or more gastrointestinal toxicity. Hence, the equation of probability of such toxicity was P = 1 1 + e - ( - 4.155 + 0.579 D mean of the intestine + 0.021 V 10 of the stomach ) Additionally, the area under the ROC curve and threshold of dose constraints of V 10 of the stomach and D mean of the intestine were 0.779 and 77.575 cc, 0.769 and 4.22 Gy3 (α/β = 3), respectively. The area under the ROC curve of the equation was 0.821. Conclusion The V 10 of the stomach and D mean of the intestine may be vital parameters to predict grade 2 or more gastrointestinal toxicity, of which the threshold of dose constraints may be beneficial for the practice of re-irradiation of locally relapsed pancreatic cancer.
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7
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van Goor IWJM, Daamen LA, Besselink MG, Bruynzeel AME, Busch OR, Cirkel GA, Groot Koerkamp B, Haj Mohammed N, Heerkens HD, van Laarhoven HWM, Meijer GJ, Nuyttens J, van Santvoort HC, van Tienhoven G, Verkooijen HM, Wilmink JW, Molenaar IQ, Intven MPW. A nationwide randomized controlled trial on additional treatment for isolated local pancreatic cancer recurrence using stereotactic body radiation therapy (ARCADE). Trials 2022; 23:913. [PMID: 36307892 PMCID: PMC9617359 DOI: 10.1186/s13063-022-06829-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/06/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Disease recurrence is the main cause of mortality after resection of pancreatic ductal adenocarcinoma (PDAC). In 20-30% of resected patients, isolated local PDAC recurrence occurs. Retrospective studies have suggested that stereotactic body radiation therapy (SBRT) might lead to improved local control in these patients, potentially having a beneficial effect on both survival and quality of life. The "nationwide randomized controlled trial on additional treatment for isolated local pancreatic cancer recurrence using stereotactic body radiation therapy" (ARCADE) will investigate the value of SBRT in addition to standard of care in patients with isolated local PDAC recurrence compared to standard of care alone, regarding both survival and quality of life outcomes. METHODS The ARCADE trial is nested within a prospective cohort (Dutch Pancreatic Cancer Project; PACAP) according to the 'Trials within Cohorts' design. All PACAP participants with isolated local PDAC recurrence after primary resection who provided informed consent for being randomized in future studies are eligible. Patients will be randomized for local therapy (5 fractions of 8 Gy SBRT) in addition to standard of care or standard of care alone. In total, 174 patients will be included. The main study endpoint is survival after recurrence. The most important secondary endpoint is quality of life. DISCUSSION It is hypothesized that additional SBRT, compared to standard of care alone, improves survival and quality of life in patients with isolated local recurrence after PDAC resection. TRIAL REGISTRATION ClinicalTrials.gov registration NCT04881487 . Registered on May 11, 2021.
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Affiliation(s)
- I W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands.
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands.
| | - L A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M G Besselink
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - A M E Bruynzeel
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Radiation Oncology, Amsterdam University Medical Center, location Vrije Universiteit, Amsterdam, the Netherlands
| | - O R Busch
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - G A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - N Haj Mohammed
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - H D Heerkens
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - H W M van Laarhoven
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center, location University of Amsterdam, Amsterdam, the Netherlands
| | - G J Meijer
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - J Nuyttens
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - G van Tienhoven
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Radiation Oncology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - H M Verkooijen
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center, location University of Amsterdam, Amsterdam, the Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - M P W Intven
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands.
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8
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Jiang L, Lyu Q, Abdelhamid AMH, Hui S, Sheng K. An efficient rectangular optimization method for sparse orthogonal collimator based small animal irradiation. Phys Med Biol 2022; 67:10.1088/1361-6560/ac910b. [PMID: 36084625 PMCID: PMC9595432 DOI: 10.1088/1361-6560/ac910b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/09/2022] [Indexed: 11/11/2022]
Abstract
Objective.Intensity-modulated radiotherapy (IMRT) is widely used in clinical radiotherapy, treating varying malignancies with conformal doses. As the test field for clinical translation, preclinical small animal experiments need to mimic the human radiotherapy condition, including IMRT. However, small animal IMRT is a systematic challenge due to the lack of corresponding hardware and software for miniaturized targets.Approach.The sparse orthogonal collimators (SOC) based on the direct rectangular aperture optimization (RAO) substantially simplified the hardware for miniaturization. This study investigates and evaluates a significantly improved RAO algorithm for complex mouse irradiation using SOC. Because the Kronecker product representation of the rectangular aperture is the main limitation of the computational performance, we reformulated matrix multiplication in the data fidelity term using multiplication with small matrices instead of the Kronecker product of the dose loading matrices. Solving the optimization problem was further accelerated using the Fast Iterative Shrinkage-Thresholding Algorithm (FISTA).Main results.Four mouse cases, including a liver, a brain tumor, a concave U-target, and a complex total marrow irradiation (TMI) case, were included in this study with manually delineated targets and OARs. Seven coplanar-field SOC IMRT (sIMRT) plans were compared with idealistic fluence map based IMRT (iIMRT) plans. For the first three cases with simpler and smaller targets, the differences between sIMRT plans and iIMRT plans in the planning target volumes (PTV) statistics are within 1%. For the TMI case, the sIMRT plans are superior in reducing hot spots (also termedDmax) of PTV, kidneys, lungs, heart, and bowel by 20.5%, 31.5%, 24.67%, 20.13%, and 17.78%, respectively. On average, in four cases in this study, the sIMRT plan conformity is comparable to that of the iIMRT's with lightly increased R50 and Integral Dose by 2.23% and 2.78%.Significance.The significantly improved sIMRT optimization method allows fast plan creation in under 1 min for smaller targets and makes complex TMI planning feasible while achieving comparable dosimetry to idealistic IMRT with fluence map optimization.
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Affiliation(s)
- Lu Jiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Qihui Lyu
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Amr M H Abdelhamid
- Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States of America
| | - Susanta Hui
- Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States of America
| | - Ke Sheng
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, United States of America
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9
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Reddy AV, Hill CS, Sehgal S, He J, Zheng L, Herman JM, Meyer J, Narang AK. Stereotactic body radiation therapy for the treatment of locally recurrent pancreatic cancer after surgical resection. J Gastrointest Oncol 2022; 13:1402-1412. [PMID: 35837183 PMCID: PMC9274026 DOI: 10.21037/jgo-22-38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/07/2022] [Indexed: 11/06/2022] Open
Abstract
Background To report on a cohort of radiation-naïve patients with pancreatic cancer who developed isolated local recurrence following surgical resection and were subsequently treated with stereotactic body radiation therapy (SBRT). Methods Patients with pancreatic cancer who were treated with SBRT for isolated local recurrence after surgical resection were retrospectively reviewed. Clinical outcomes were calculated from completion of SBRT and included overall survival (OS), local progression-free survival (LPFS), distant metastasis-free survival (DMFS), and progression-free survival (PFS). Univariate (UVA) analysis was performed to identify variables associated with clinical outcomes. Kaplan-Meier method was used for survival outcomes. Toxicity was assessed using the Common Terminology Criteria for Adverse Events version 4.0. Results From September 2012 to November 2018, a total of 19 patients with localized pancreatic cancer were treated with SBRT for isolated local recurrence after initial surgical resection. No patients had prior radiation. The median biologically effective dose (BED10) was 54.8 Gy (range, 37.5-54.8 Gy). Median OS was 17.1 months, with 6-month and 1-year OS rates of 94.4% and 69.6%, respectively. Nine patients (47.4%) developed local failure after SBRT. Pattern of first failure after SBRT was distant in 7 patients (46.7%), local in 5 patients (33.3%), and synchronous distant and local in 3 patients (20.0%). One patient developed local failure after developing distant disease first. Of the 9 local failures, 3 (33.3%) were out-of-field. Median LPFS was 22.2 months, with 6-month and 1-year LPFS rates of 86.9% and 63.2%, respectively. A BED10 <54.8 Gy was associated with inferior LPFS (1-year, 25.0% vs. 80.2%, P<0.009). Median DMFS and PFS were 15.6 months. There was 1 case (5.3 %) of grade 3 gastric perforation. There were no cases of grade 4-5 toxicity events. Conclusions SBRT for locally recurrent pancreatic cancer after initial curative resection is safe and feasible. A BED10 <54.8 Gy was significantly associated with inferior local control. Further studies investigating dose escalation and optimal treatment volumes in the locally recurrent setting are warranted.
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Affiliation(s)
- Abhinav V. Reddy
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Colin S. Hill
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Shuchi Sehgal
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Joseph M. Herman
- Department of Radiation Oncology, Northwell Health, New Hyde Park, NY, USA
| | - Jeffrey Meyer
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Amol K. Narang
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
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10
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Floberg JM, Blitzer GC, Yadav P. Use of stereotactic magnetic resonance-guided online adaptive radiation therapy for treatment of a pelvic recurrence of prostate cancer in a patient with an orthotopic neobladder. Adv Radiat Oncol 2022; 7:100958. [PMID: 35647410 PMCID: PMC9130090 DOI: 10.1016/j.adro.2022.100958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/23/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- John M. Floberg
- Department of Human Oncology, University of Wisconsin School of Medicine; and Public Health, Madison, Wisconsin
- Corresponding author.
| | - Grace C. Blitzer
- Department of Human Oncology, University of Wisconsin School of Medicine; and Public Health, Madison, Wisconsin
| | - Poonam Yadav
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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11
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Chuong MD, Bryant JM, Herrera R, McCulloch J, Contreras J, Kotecha R, Romaguera T, Alvarez D, Hall MD, Rubens M, Mehta MP, Kaiser A, Tom M, Gutierrez AN, Mittauer KE. Dose-Escalated Magnetic Resonance Image–Guided Abdominopelvic Reirradiation With Continuous Intrafraction Visualization, Soft Tissue Tracking, and Automatic Beam Gating. Adv Radiat Oncol 2022; 7:100840. [PMID: 35146215 PMCID: PMC8802055 DOI: 10.1016/j.adro.2021.100840] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/01/2021] [Accepted: 10/05/2021] [Indexed: 11/03/2022] Open
Abstract
Purpose Methods and Materials Results Conclusions
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12
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Jing S, Jiang C, Ji X, Qiu X, Li J, Sun X, Zhu X. Study on Motion Management of Pancreatic Cancer Treated by CyberKnife. Front Oncol 2021; 11:767832. [PMID: 34926273 PMCID: PMC8674533 DOI: 10.3389/fonc.2021.767832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/08/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose We investigated the movement characteristics of pancreas and the clinical accuracy of tracking pancreas with the Synchrony Respiratory Tracking System (SRTS) during the CyberKnife treatment. These data provide a clinical data basis for the expansion margins of pancreatic tumor target. Methods and Materials Forty-two patients with pancreatic cancer treated by CyberKnife were retrospectively studied. The pancreatic displacement calculated from the x-ray images collected during the time interval between two consecutive movements constituted a data set. Results The total mean motion amplitudes and standard deviations of pancreatic tumors in SI, LR, AP, and radial directions were 3.66 ± 1.71 mm, 0.97 ± 0.62 mm, 1.52 ± 1.02 mm, and 1.36 ± 0.49 mm, respectively. The overall mean correlation errors and standard deviations were 0.82 ± 0.46 mm, 0.47 ± 0.33 mm, 0.41 ± 0.24 mm, and 0.98 ± 0.37 mm, respectively. The overall mean prediction errors and standard deviations were 0.57 ± 0.14 mm, 0.62 ± 0.28 mm, 0.39 ± 0.17 mm, and 1.58 ± 0.36 mm, respectively. The correlation errors and prediction errors of pancreatic tumors at different anatomical positions in SI, LR, and AP directions were statistically significant (p < 0.05). Conclusions The tumor motion amplitude, the tumor location, and the treatment time are the main factors affecting the tracking accuracy. The pancreatic tumors at different anatomical locations should be treated differently to ensure sufficient dose coverage of the pancreatic target area.
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Affiliation(s)
- Shenghua Jing
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Changchen Jiang
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Xiaoqin Ji
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Xiangnan Qiu
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Jing Li
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Xiangdong Sun
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Xixu Zhu
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
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13
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Shen Y, Zhu X, Cao F, Xie H, Ju X, Cao Y, Qing S, Jia Z, Gu L, Fang F, Zhang H. Re-Irradiation With Stereotactic Body Radiotherapy for In-Field Recurrence of Pancreatic Cancer After Prior Stereotactic Body Radiotherapy: Analysis of 24 Consecutive Cases. Front Oncol 2021; 11:729490. [PMID: 34796108 PMCID: PMC8593208 DOI: 10.3389/fonc.2021.729490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/05/2021] [Indexed: 12/27/2022] Open
Abstract
Purpose/Objectives Locally recurrent pancreatic cancer is a therapeutic challenge, and aggressive approaches are needed to improve its clinical outcomes. Stereotactic body radiotherapy (SBRT) is a promising treatment for pancreatic cancer with an excellent local control and acceptable toxicity. However, the safety and efficacy of SBRT for in-field recurrence after initial SBRT remain unknown. The aim of the study was to investigate the feasibility of re-irradiation with SBRT for locally recurrent pancreatic cancer after prior definitive SBRT. Material/Methods Twenty-four consecutive patients with pancreatic cancer received two courses of SBRT in our center between January 2014 and December 2016. The median prescription dose of the initial and second courses of SBRT was 35.5 Gy/5–7f and 32 Gy/5–8f, respectively. Clinical outcomes including overall survival (OS), disease control, and toxicity were evaluated after treatment. Results The median interval between two courses of SBRT was 13 months (range: 6–29 months). From the first SBRT, the median OS of 18 patients with limited diseases was 26 months (95% CI: 19.1–32.95 months). The median OS of 12 patients without metastasis was 14 months (95% CI: 10.6–17.4 months) from re-irradiation of SBRT. The overall response rate and disease control rate were 50% and 13%, and 100% and 86.9% after each SBRT, respectively. Carbohydrate antigen 19-9 (CA19-9) levels declined dramatically after re-irradiation within 1 month (p = 0.002) and 3 months (p = 0.028). Twelve (75%) out of 16 patients had pain relief after re-irradiation. None of the patients experienced gastrointestinal toxicity. Conclusions Re-irradiation with SBRT can provide favorable outcomes and effective analgesia with mild toxicity after prior SBRT for in-field recurrent pancreatic cancer, which might be feasible for locally relapsed pancreatic cancer.
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Affiliation(s)
- Yuxin Shen
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Xiaofei Zhu
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Fei Cao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Hongliang Xie
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Xiaoping Ju
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Yangsen Cao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Shuiwang Qing
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Zhen Jia
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Lei Gu
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Fang Fang
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Huojun Zhang
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
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14
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Ghaly M, Gogineni E, Herman J, Saif MW. New Potential Options for SBRT in Pancreatic Cancer. CANCER MEDICINE JOURNAL 2021; 4:41-50. [PMID: 34355218 PMCID: PMC8336074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Stereotactic body radiotherapy (SBRT) is an emerging treatment option for patients with pancreatic cancer, as it can provide a therapeutic benefit with significant advantages for patients' quality of life over standard conventional chemoradiation (CRT). The objective of this review is to present alternative clinical settings in which SBRT may benefit patients with pancreatic cancer. These include palliation of pain, elderly patients who are not surgical candidates, local therapy in oligometastatic cases and salvaging local failures after surgery or external beam radiation. We will review these individually and provide supporting literature for each.
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Affiliation(s)
- Maged Ghaly
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Emile Gogineni
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Joseph Herman
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Muhammad W Saif
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
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15
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Dosimetric and radiobiological comparison of treatment plan between CyberKnife and EDGE in stereotactic body radiotherapy for pancreatic cancer. Sci Rep 2021; 11:4065. [PMID: 33603030 PMCID: PMC7893157 DOI: 10.1038/s41598-021-83648-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 02/03/2021] [Indexed: 11/09/2022] Open
Abstract
To perform a comparison of the different stereotactic body radiotherapy (SBRT) plans between the Varian EDGE and CyberKnife (CK) systems for locally advanced unresectable pancreatic cancer. Fifteen patients with pancreatic cancer were selected in this study. The median planning target volume (PTV) was 28.688 cm3 (5.736–49.246 cm3). The SBRT plans for the EDGE and CK were generated in the Eclipse and Multiplan systems respectively with the same contouring and dose constrains for PTV and organs at risk (OARs). Dose distributions in PTV were evaluated in terms of coverage, conformity index (CI), new conformity index (nCI), homogeneity index (HI), and gradient index (GI). OARs, including spinal cord, bowel, stomach, duodenum and kidneys were statistically evaluated by different dose-volume metrics and equivalent uniform dose (EUD). The volume covered by the different isodose lines (ISDL) ranging from 10 to 100% for normal tissue were also analyzed. All SBRT plans for EDGE and CK met the dose constraints for PTV and OARs. For the PTV, the dosimetric metrics in EDGE plans were lower than that in CK, except that D99 and GI were slightly higher. The EDGE plans with lower CI, nCI and HI were superior to generate more conformal and homogeneous dose distribution for PTV. For the normal tissue, the CK plans were better at OARs sparing. The radiobiological indices EUD of spinal cord, duodenum, stomach, and kidneys were lower for CK plans, except that liver were higher. The volumes of normal tissue covered by medium ISDLs (with range of 20–70%) were lower for CK plans while that covered by high and low ISDLs were lower for EDGE plans. This study indicated that both EDGE and CK generated equivalent plan quality, and both systems can be considered as beneficial techniques for SBRT of pancreatic cancer. EDGE plans offered more conformal and homogeneous dose distribution for PTV, while the CK plans could minimize the exposure of OARs.
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16
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Okamoto M, Shiba S, Okazaki S, Miyasaka Y, Shibuya K, Kiyohara H, Ohno T. Feasibility and Safety of Repeated Carbon Ion Radiotherapy for Locally Advanced Unresectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13040665. [PMID: 33562274 PMCID: PMC7914638 DOI: 10.3390/cancers13040665] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Despite the effectiveness of carbon ion radiotherapy (CIRT) for locally advanced unresectable pancreatic cancer (URPC), isolated local recurrence after CIRT is a therapeutic challenge. Herein, we aimed to evaluate the feasibility and safety of a second course of CIRT for locally recurrent URPC in 10 patients. One patient developed grade 3 diarrhea immediately after the second CIRT; no other grade 3 or higher adverse events were induced by CIRT. The estimated 1-year overall survival rate and local control rate after the second CIRT were 48% and 67%, respectively. Repeated CIRT is feasible with acceptable toxicity for selected patients with locally advanced URPC after CIRT. Abstract Purpose: The feasibility and safety of re-irradiation with carbon ion beams for locally recurrent unresectable pancreatic cancer (URPC) after carbon ion radiotherapy (CIRT) was evaluated. Methods: Medical records from patients with re-irradiated URPC who were treated with CIRT between November 2017 and February 2019 were reviewed. Inclusion criteria were (1) isolated local recurrence after CIRT, (2) URPC, and (3) tumor located at least 3 mm from the gastrointestinal tract. The first and second CIRT irradiation doses were 55.2 Gy (relative biological effectiveness) in 12 fractions. Results: Ten patients met the inclusion criteria. The median follow-up period was 25.5 months (range, 16.0–69.1) after the first CIRT and 8.9 months (range, 6.4–18.9) after the second CIRT. The median interval between the initial CIRT and the local recurrence was 15.8 months (range, 8.0–50.1). One patient developed grade 3 diarrhea immediately after the second CIRT; no other grade 3 or higher adverse events were attributed to CIRT. The estimated 1-year overall survival, local control, and progression-free survival rates after the second CIRT were 48%, 67%, and 34%, respectively. Conclusion: Repeated CIRT is feasible with acceptable toxicity for selected patients with locally advanced URPC after CIRT.
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Affiliation(s)
- Masahiko Okamoto
- Gunma University Heavy-ion Medical Center, Gunma University Graduate School of Medicine, Gunma 371-0811, Japan; (S.S.); (S.O.); (Y.M.); (K.S.); (T.O.)
- Correspondence:
| | - Shintaro Shiba
- Gunma University Heavy-ion Medical Center, Gunma University Graduate School of Medicine, Gunma 371-0811, Japan; (S.S.); (S.O.); (Y.M.); (K.S.); (T.O.)
| | - Shohei Okazaki
- Gunma University Heavy-ion Medical Center, Gunma University Graduate School of Medicine, Gunma 371-0811, Japan; (S.S.); (S.O.); (Y.M.); (K.S.); (T.O.)
| | - Yuhei Miyasaka
- Gunma University Heavy-ion Medical Center, Gunma University Graduate School of Medicine, Gunma 371-0811, Japan; (S.S.); (S.O.); (Y.M.); (K.S.); (T.O.)
| | - Kei Shibuya
- Gunma University Heavy-ion Medical Center, Gunma University Graduate School of Medicine, Gunma 371-0811, Japan; (S.S.); (S.O.); (Y.M.); (K.S.); (T.O.)
| | - Hiroki Kiyohara
- Japanese Red Cross Maebashi Hospital, Gunma 371-0811, Japan;
| | - Tatsuya Ohno
- Gunma University Heavy-ion Medical Center, Gunma University Graduate School of Medicine, Gunma 371-0811, Japan; (S.S.); (S.O.); (Y.M.); (K.S.); (T.O.)
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17
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Chang DT, Koay EJ, Herman JM, Hong TS, Das P. Abdominal and Pelvic Reirradiation for Recurrent Gastrointestinal Cancers. Semin Radiat Oncol 2020; 30:232-237. [PMID: 32503788 DOI: 10.1016/j.semradonc.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Local recurrences can sometimes occur after prior radiotherapy for abdominal and pelvic cancers. The management of these patients can be quite complex. We present a case of recurrent pancreatic cancer after prior chemoradiation and discuss various management options, with a focus on different approaches to reirradiation.
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Affiliation(s)
- Daniel T Chang
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA.
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph M Herman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Prajnan Das
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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18
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Analysis of the efficacy, safety and survival factors of stereotactic body radiation therapy in patients with recurrence of pancreatic cancer. Transl Oncol 2020; 13:100818. [PMID: 32592902 PMCID: PMC7327753 DOI: 10.1016/j.tranon.2020.100818] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023] Open
Abstract
Objective: This study aims to evaluate the efficacy and safety of stereotactic body radiation therapy (SBRT) using Cyber Knife (CK) in the treatment of patients with recurrent pancreatic cancer after surgery, and analyze its survival-related factors. Methods: The primary endpoint was freedom from local progression (FFLP) and local control (LC) rate after CK. The secondary endpoints were overall survival (OS), progression-free survival (PFS), symptom relief and toxicities. Receiver operating characteristic (ROC) curves were used to determine the optimal cut-off values of inflammatory composite indicators NLR, PLR, SII and PNI. The prognostic factors that affected these patients were analyzed by univariate and multivariate analysis, respectively. Results: A total of 27 patients were enrolled. Median local recurrence disease free interval(DFI)was 11.3 (1.3-30.6) months, LC was 81.5% and 37.0% at 6 and 12 months, respectively. Median PFS was 7.1 (1.3-27.1) months. Median OS was 11.3 (1.3-30.6) months. Symptom alleviation was observed in 16 of 17 patients (94.1%) within 2 weeks after CK. Subsequent chemotherapy, CA199≥50% decrease after CK were independent prognostic factors for OS (all P <0.05). Conclusion: SBRT is a safe and effective treatment approach for recurrent pancreatic adenocarcinoma. Encouraging local control rate, low toxicity, and effective symptom relief suggests the vital role of CK in the treatment of these patients. This clinical application needs to be further studied in the combination of CK and multimodal therapy.
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Barsky AR, Reddy VK, Plastaras JP, Ben-Josef E, Metz JM, Wojcieszynski AP. Proton beam re-irradiation for gastrointestinal malignancies: a systematic review. J Gastrointest Oncol 2020; 11:187-202. [PMID: 32175122 DOI: 10.21037/jgo.2019.09.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Radiotherapy (RT) is part of the standard of care management of most gastrointestinal (GI) cancers. Even with advanced RT, systemic therapy, and surgical techniques, locoregional recurrences or second primary cancers can still occur within previously irradiated fields, which can present challenges in delivering effective and safe treatment. Options for reirradiation are often limited, but given the favorable dosimetric aspects of proton-beam RT, it may provide an effective and safe re-irradiation option for patients with recurrent or second primary GI cancers. Methods We conducted a systematic review as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement protocol, assessing for reports of proton-beam reirradiation for recurrent or second primary GI cancers, primarily via PubMed. From the initial 373 articles identified, 7 articles were ultimately included in the analysis. Results The 7 included studies reported on proton-beam re-irradiation for the following disease sites: esophageal (n=2), pancreas (n=1), liver (n=2), rectal (n=1), and anal (n=1). Study sizes varied from as few as 1 to as many as 83 patients. Across studies, in patients who presented with tumor-related symptoms, palliation (stability/improvement) was achieved in 80-100% of the cases. Local control rates, with variable follow-up, ranged from 36-100%. All median overall survival values, when reported, were greater than 1 year. Across both liver studies, there were no cases of radiation-induced liver disease (RILD) from proton-beam re-irradiation. Across all studies, there were 2 acute (esophagopleural fistula in esophageal cancer, small bowel perforation in pancreatic cancer) and 1 late (esophageal ulcer in esophageal cancer) grade 5 toxicities, all favored to be due to progressive disease, rather than proton-beam re-irradiation. Two studies (1 esophageal, 1 rectal) generated comparison photon plans. One found that proton therapy reduced mean heart and lung doses, spinal cord dose, and lung V5Gy as compared to photon treatment, while resulting in higher lung V20Gy and V30Gy. The other found that protons decreased bowel V10Gy, V20Gy, and the dose to 200 and 150 cc of bowel, as compared to photons. Conclusions Based upon the published experiences, proton-beam re-irradiation for recurrent or second primary GI cancers appears effective for palliation, with good disease-control, limited toxicity, favorable dosimetry, and overall compares well with published non-proton-beam experiences. Given short follow-up, additional studies are warranted to determine if dosimetric advantages from proton therapy will translate into comparative toxicity benefits.
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Affiliation(s)
- Andrew R Barsky
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - Vishruth K Reddy
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - Edgar Ben-Josef
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - James M Metz
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - Andrzej P Wojcieszynski
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
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20
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Dell’Oro M, Short M, Wilson P, Bezak E. Clinical Limitations of Photon, Proton and Carbon Ion Therapy for Pancreatic Cancer. Cancers (Basel) 2020; 12:cancers12010163. [PMID: 31936565 PMCID: PMC7017270 DOI: 10.3390/cancers12010163] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction: Despite improvements in radiation therapy, chemotherapy and surgical procedures over the last 30 years, pancreatic cancer 5-year survival rate remains at 9%. Reduced stroma permeability and heterogeneous blood supply to the tumour prevent chemoradiation from making a meaningful impact on overall survival. Hypoxia-activated prodrugs are the latest strategy to reintroduce oxygenation to radioresistant cells harbouring in pancreatic cancer. This paper reviews the current status of photon and particle radiation therapy for pancreatic cancer in combination with systemic therapies and hypoxia activators. Methods: The current effectiveness of management of pancreatic cancer was systematically evaluated from MEDLINE® database search in April 2019. Results: Limited published data suggest pancreatic cancer patients undergoing carbon ion therapy and proton therapy achieve a comparable median survival time (25.1 months and 25.6 months, respectively) and 1-year overall survival rate (84% and 77.8%). Inconsistencies in methodology, recording parameters and protocols have prevented the safety and technical aspects of particle therapy to be fully defined yet. Conclusion: There is an increasing requirement to tackle unmet clinical demands of pancreatic cancer, particularly the lack of synergistic therapies in the advancing space of radiation oncology.
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Affiliation(s)
- Mikaela Dell’Oro
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide SA 5001, Australia; (M.S.); (E.B.)
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide SA 5000, Australia;
- Correspondence: ; Tel.: +61-435214264
| | - Michala Short
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide SA 5001, Australia; (M.S.); (E.B.)
| | - Puthenparampil Wilson
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide SA 5000, Australia;
- School of Engineering, University of South Australia, Adelaide SA 5001, Australia
| | - Eva Bezak
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide SA 5001, Australia; (M.S.); (E.B.)
- Department of Physics, University of Adelaide, Adelaide SA 5005, Australia
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21
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Woods K, Neph R, Nguyen D, Sheng K. A sparse orthogonal collimator for small animal intensity-modulated radiation therapy. Part II: hardware development and commissioning. Med Phys 2019; 46:5733-5747. [PMID: 31621091 DOI: 10.1002/mp.13870] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 12/18/2022] Open
Abstract
PURPOSE A dose-modulation device for small animal radiotherapy is required to use clinically analogous treatment techniques, which will likely increase the translatability of preclinical research results. Because the clinically used multileaf collimator (MLC) is impractical for miniaturization, we have developed a simpler, better-suited sparse orthogonal collimator (SOC) for delivering small animal intensity-modulated radiation therapy (IMRT) using a rectangular aperture optimization (RAO) treatment planning system. METHODS The SOC system was modeled in computer-aided design software and fabricated with machined tungsten leaves and three-dimensional (3D) printed leaf housing. A graphical user interface was developed for controlling and calibrating the SOC leaves, which are driven by Arduino-controlled stepper motors. A Winston-Lutz test was performed to assess mechanical alignment, and abutting field and grid dose patterns were created to analyze intra- and intercalibration leaf positioning error. Leaf transmission and penumbra were measured over the full range of gantry angles and leaf positions, respectively. Three SOC test plans were delivered, and film measurements were compared to the intended dose distributions. The differences in maximum, mean, and minimum, as well as pixelwise absolute dose differences, were compared for each structure, and a gamma analysis was performed for the target structures using criteria of 4% dose difference and 0.3 mm distance to agreement. RESULTS The Winston-Lutz test revealed maximum directional offsets between the SOC and primary collimator axes of 0.53 mm at 0° and 0.68 mm over the full 360°. Upper and lower abutting field patterns had maximum dose deviations of 18.8 ± 3.1% and 15.5 ± 2.9%, respectively, and grid patterns showed intra- and intercalibration repeatability of 93% and 91%, respectively. Extremely low midleaf (0.15 ± 0.05%) and interleaf (0.27 ± 0.22%) transmission was measured, with no significant rotational variation. The average penumbra was ~0.8 mm for all leaves at field center, with a range of 0.17 mm for all leaf positions. A highly concave test plan was delivered with a ~ 95% gamma analysis pass rate, and a realistic mouse phantom liver irradiation plan achieved a pass rate of ~98%. A highly complex dose distribution was also created with 551 SOC apertures averaging 2.4 mm in size. CONCLUSIONS A sparse orthogonal collimator was developed and commissioned, with promising preliminary dosimetry results. The SOC design, with its limited moving components and high dose-modulation resolution, is ideal for delivering high-quality small animal IMRT with our RAO-based treatment planning system.
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Affiliation(s)
- Kaley Woods
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Ryan Neph
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Dan Nguyen
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Ke Sheng
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
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22
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Shi W, Jiang R, Liang F, Yu G, Long J, Zhao J. Definitive chemoradiotherapy and salvage chemotherapy for patients with isolated locoregional recurrence after radical resection of primary pancreatic cancer. Cancer Manag Res 2019; 11:5065-5073. [PMID: 31213918 PMCID: PMC6549434 DOI: 10.2147/cmar.s202543] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/16/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose: The objective of this study was to analyze the safety and efficacy of definitive chemoradiotherapy and salvage chemotherapy in pancreatic cancer (PC) patients with isolated locoregional recurrence after radical resection and assess the factors associated with tumor response. Patients and methods: A retrospective study of isolated locoregional recurrent PC patients who were treated with definitive chemoradiotherapy and salvage chemotherapy at our institution between 2012 and 2017 was conducted. Medium dose of 56.0 Gy (range: 54.0 Gy - 60.2 Gy) in 1.8 Gy to 2.15 Gy daily fractions was prescribed to the PTV-G and 50.4 Gy was prescribed to the PTV-C. Patients received chemotherapy before, at the same time with or after radiotherapy. The overall survival (OS) and freedom from locoregional progression (FFLP) rates were estimated by the Kaplan-Meier method, and the log-rank test was performed to compare survival curves. The Cox regression was used to identify factors affecting response to treatment and survival. Results: Thirty-one patients were included. The median interval from the resection of primary PC to the diagnosis of the locoregional recurrence (DFI) was 7.4 months (range 0.2-44.6). Within a median follow-up from the start of radiotherapy (RT) of 31.7 months (95% CI: 20.0-43.5 months), the medium OS and FFLP rates from the start of RT were 23.6 and 12.0 months, respectively. DFI >6 months was shown to be a significant factor associated with favorable OS. Acute and late toxicity of grade 3 occurred in 3 patients (9.7%) and 1 patient (3.2%) respectively. No grade 4 toxicity or higher occurred. Conclusions: This single-institution retrospective analysis identified definitive chemoradiotherapy and salvage chemotherapy to be a feasible and tolerable treatment strategy for patients with isolated locoregional recurrence after radical resection of primary PC.
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Affiliation(s)
- Wei Shi
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Shanghai, People's Republic of China
| | - Rui Jiang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Shanghai, People's Republic of China
| | - Fei Liang
- Clinical Statistic Center, Shanghai Cancer Center and Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Genhua Yu
- Department of Radiation Oncology, Zhebei Mingzhou Hospital, Huzhou City, Zhejiang Province, People's Republic of China
| | - Jiang Long
- Department of Oncology, Shanghai Medical College, Shanghai, People's Republic of China.,Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
| | - Jiandong Zhao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Shanghai, People's Republic of China
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23
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Clinical safety and efficacy of salvage reirradiation for upper abdominal malignancies. Strahlenther Onkol 2019; 195:526-533. [PMID: 30689025 DOI: 10.1007/s00066-018-01420-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/22/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Reirradiation has the potential to provide effective local control of upper abdominal malignancies. This study aimed to evaluate the safety and efficacy of reirradiation for upper abdominal malignancies. METHODS A total of 42 patients with a history of prior radiotherapy (RT) received reirradiation for abdominal malignancies between 2005 and 2017. Each patient's medical records, contours, and dose distribution for both RT courses were reviewed. The median dose of the prior RT was 50.0 Gy (range, 30.0-60.0 Gy) and the median dose of reirradiation was 45.0 Gy (range, 15.0-75.0 Gy). RESULTS With a median follow-up of 10.9 months, the median infield-failure-free survival (IFFS) rate was 9.2 months. Gross tumor volume (GTV) significantly related to IFFS in both the univariate (p = 0.009) and multivariate analyses (p = 0.024), and patients with a GTV of <60.0 mL had an improved IFFS (p = 0.001). Four patients experienced ≥grade 3 late toxicities. In the retrospective dose reconstruction analysis in these patients, the cumulative dose to the most exposed 2 cc (D2cc) of the duodenum was >60.0 Gy (range, 60.1-73.7 Gy). In the univariate analysis, the D2cc of the duodenum and a preexisting duodenal ulcer identified using endoscopy prior to reirradiation significantly correlated with late severe toxicity (p = 0.021 and 0.017, respectively). CONCLUSIONS Reirradiation for upper abdominal malignancies could be safely performed for patients without preexisting gastrointestinal morbidity unless the duodenum received excessive radiation doses. Reirradiation could also provide substantial IFFS, especially for patients with a GTV of <60.0 mL.
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24
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CyberKnife MLC-based treatment planning for abdominal and pelvic SBRT: Analysis of multiple dosimetric parameters, overall scoring index and clinical scoring. Phys Med 2018; 56:25-33. [DOI: 10.1016/j.ejmp.2018.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 11/13/2018] [Accepted: 11/17/2018] [Indexed: 12/31/2022] Open
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25
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Gkika E, Strouthos I, Kirste S, Adebahr S, Schultheiss M, Bettinger D, Fritsch R, Brass V, Maruschke L, Neeff HP, Lang SA, Nestle U, Grosu AL, Brunner TB. Repeated SBRT for in- and out-of-field recurrences in the liver. Strahlenther Onkol 2018; 195:246-253. [DOI: 10.1007/s00066-018-1385-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 10/09/2018] [Indexed: 12/21/2022]
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26
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Zhu X, Li F, Ju X, Shen Y, Cao Y, Cao F, Fang F, Qing S, Jia Z, Zhang H. Prediction of overall survival after re-irradiation with stereotactic body radiation therapy for pancreatic cancer with a novel prognostic model (the SCAD score). Radiother Oncol 2018; 129:313-318. [PMID: 30217337 DOI: 10.1016/j.radonc.2018.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/23/2018] [Accepted: 08/03/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To develop a predictive model for stratification of patients with pancreatic cancer who may achieve survival benefits from re-irradiation with stereotactic body radiation therapy (SBRT). METHODS The score was developed based on clinical predictors of OS in 31 patients receiving two courses of SBRT with Cox proportional hazards model. Results were then validated in another cohort with 11 participants to assess the performance of the score. RESULTS In the training cohort, the median BED10 of the first and second SBRT was 59.5 Gy (48-85.5 Gy) and 50.2 Gy (43.7-66.9 Gy) in 5-8 fractions, while in the validation cohort, the median BED10 of the first and second SBRT was 59.5 Gy (52.5-66.9 Gy) and 47.7 Gy (40.6-54.8 Gy) in 5-8 fractions. The interval between the first and second SBRT of the training cohort and validation cohort was 10.5 months (6.1-24.3 months) and 12.8 months (6.5-29.1 months), respectively. Multivariable analysis showed that tumor stage (P = 0.005), BED10 (P = 0.006) and CA19-9 response (P = 0.04) were significantly predictive of overall survival, which formed SCAD score (named after the initials of factors). Patients with the score < 3 points had a superior OS compared with those with the score ≥ 3 points in the validation cohort (median OS has not been reached vs. 15.9 months, P = 0.032). CONCLUSIONS The SCAD score may have the potential to identify individuals benefiting from re-SBRT and be a step toward more personalized medicine.
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Affiliation(s)
- Xiaofei Zhu
- Department of Radiation Oncology, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Fuqi Li
- Department of Radiation Oncology, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Xiaoping Ju
- Department of Radiation Oncology, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Yuxin Shen
- Department of Radiation Oncology, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Yangsen Cao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Fei Cao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Fang Fang
- Department of Radiation Oncology, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Shuiwang Qing
- Department of Radiation Oncology, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Zhen Jia
- Department of Radiation Oncology, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Huojun Zhang
- Department of Radiation Oncology, Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China.
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27
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Hunt A, Das P, Minsky BD, Koay EJ, Krishnan S, Herman JM, Taniguchi C, Koong A, Smith GL, Holliday EB. Hyperfractionated abdominal reirradiation for gastrointestinal malignancies. Radiat Oncol 2018; 13:143. [PMID: 30086784 PMCID: PMC6081944 DOI: 10.1186/s13014-018-1084-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/23/2018] [Indexed: 12/14/2022] Open
Abstract
Background We sought to determine the role of abdominal reirradiation for patients presenting with recurrent or new primary gastrointestinal (GI) malignancies. At our institution, we have established a hyperfractionated, accelerated reirradiation regimen consisting of 39 Gray (Gy) in 26 twice-daily fractions. Although this regimen is used frequently in the pelvis, we sought to determine its toxicity and efficacy for abdominal tumors. Methods Twenty-four patients who received abdominal reirradiation with a hyperfractionated, accelerated approach from 2000 to 2017 were identified. Overall survival (OS) and local progression-free survival (LPFS) were calculated using the Kaplan-Meier method. Several patient, tumor and treatment characteristics were evaluated on univariate analyses for association with OS and LPFS using a Cox proportional hazards model. Results Of the twenty-four patients identified, the majority (n = 11, 46%) had pancreatic adenocarcinoma as their primary disease but also included upper GI adenocarcinoma (n = 4), colon adenocarcinoma (n = 3), hepatobiliary cancers (n = 4) and other malignancies (n = 2). The majority of patients received 45–50.4Gy in 1.8Gy fractions as their initial abdominal radiation course. The median reirradiation dose was 39Gy in 26 twice-daily fractions with a minimum six hour interval. The median [interquartile range (IQR)] interval between the courses of radiotherapy was 28 [18.6–38.9] months. Only palliative reirradiation intent was associated with decreased OS. While colon adenocarcinoma primary was significantly associated with increased LPFS, the sample size was small (n = 3). The 1-yr rate of LPFS was 38%. The median [IQR] duration of freedom from local progression was 8 [3.8–19.2] months. The 1-year OS was 50% and the median (IQR) OS was 14 [6.3–19.6] months. Thirteen patients (54%) had acute side effects with one patient experiencing G3 nausea and one experiencing a G4 bleed; the remaining patients experienced G1-G2 symptoms. Conclusion Hyperfractionated, accelerated reirradiation to the abdomen was relatively well-tolerated but provided limited local control to recurrent or second primary abdominal malignancies. Reirradiation could play a role in treating these patients with palliative or curative intent, but alternative strategies for delivering increased biologically effective dose should be further explored.
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Affiliation(s)
- Andrew Hunt
- University of Texas Health San Antonio Long School of Medicine, San Antonio, TX, USA
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 97, Houston, TX, 77030, USA
| | - Bruce D Minsky
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 97, Houston, TX, 77030, USA
| | - Eugene J Koay
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 97, Houston, TX, 77030, USA
| | - Sunil Krishnan
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 97, Houston, TX, 77030, USA
| | - Joseph M Herman
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 97, Houston, TX, 77030, USA
| | - Cullen Taniguchi
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 97, Houston, TX, 77030, USA
| | - Albert Koong
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 97, Houston, TX, 77030, USA
| | - Grace L Smith
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 97, Houston, TX, 77030, USA
| | - Emma B Holliday
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 97, Houston, TX, 77030, USA.
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28
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Bazire L, Darmon I, Calugaru V, Costa É, Dumas JL, Kirova YM. [Technical aspects and indications of extracranial stereotactic radiotherapy]. Cancer Radiother 2018; 22:447-458. [PMID: 30064828 DOI: 10.1016/j.canrad.2017.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/10/2017] [Accepted: 09/16/2017] [Indexed: 12/25/2022]
Abstract
Extracranial stereotactic radiotherapy has developed considerably in recent years and is now an important part of the therapeutic alternatives to be offered to patients with cancer. It offers opportunities that have progressively led physicians to reconsider the therapeutic strategy, for example in the case of local recurrence in irradiated territory or oligometastatic disease. The literature on the subject is rich but, yet, there is no real consensus on therapeutic indications. This is largely due to the lack of prospective, randomized studies that have evaluated this technique with sufficient recoil. We propose a review of the literature on the technical aspects and indications of extracranial stereotactic radiotherapy.
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Affiliation(s)
- L Bazire
- Département de radiothérapie oncologie, institut Curie, 25, rue d'Ulm, 75005 Paris, France.
| | - I Darmon
- Département de radiothérapie oncologie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - V Calugaru
- Département de radiothérapie oncologie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - É Costa
- Département de radiothérapie oncologie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - J-L Dumas
- Département de radiothérapie oncologie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - Y M Kirova
- Département de radiothérapie oncologie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
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29
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Sutera PA, Bernard ME, Wang H, Heron DE. Prognostic Factors for Elderly Patients Treated With Stereotactic Body Radiation Therapy for Pancreatic Adenocarcinoma. Front Oncol 2018; 8:282. [PMID: 30101127 PMCID: PMC6072866 DOI: 10.3389/fonc.2018.00282] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/05/2018] [Indexed: 12/26/2022] Open
Abstract
Introduction: Pancreatic ductal adenocarcinoma (PDAC) commonly presents later in life with a median age at diagnosis of 70 years. Unfortunately, elderly patients are significantly underrepresented in clinical trials. Stereotactic body radiation therapy (SBRT) is a promising treatment modality in this population as it has demonstrated excellent local control with minimal toxicity. We aimed to determine prognostic factors associated with outcomes in elderly patients treated with SBRT. Materials and Methods: Elderly patients older than 70 treated with SBRT for PDAC at our institution, from 2004 to 2014 were included. Our primary endpoints included overall survival (OS) and local-progression-free survival (LPFS). Secondary endpoints included regional-progression-free survival (RPFS), distant-progression-free-survival (DPFS) and radiation toxicity. Endpoints were analyzed with the Kaplan-Meier method. The association of these survival endpoints with risk factors was studied with Cox proportional hazards models. Results: We identified 145 patients with 146 lesions of pancreatic adenocarcinoma with a median age at diagnosis of 79 (range, 70.1-90.3). SBRT was delivered to a median dose of 36 Gy (IQR 24-36). Surgical resection was performed on 33.8% of the total patients. Median follow-up was 12.3 months (IQR 6.0-23.3 months) and the median survival for the entire cohort 14.0 months with a 2-year OS of 27%. Multivariate analysis (MVA) demonstrated surgery [p ≤ 0.0001, HR 0.29 (95% CI, 0.16-0.51)] and post-SBRT CA19-9 [p = 0.009, HR 1.0004 (95% CI, 1.0002-1.0005)] significantly associated with overall survival. Recurrent lesions [p = 0.0069, HR 5.1 (95% CI, 1.56-16.64)] and post-SBRT CA19-9 levels [p = 0.0107, HR 1.0005 (95% CI, 1.0001-1.0008)] were significantly associated with local control on MVA. For the entire cohort, 4.1% experienced acute grade 2+ toxicity, and 2% experienced late grade 2+ toxicity at 2 years. Conclusion: This review demonstrates prognostic factors in elderly patients with PDAC treated with SBRT. We identified surgical resection and post-SBRT CA 19-9 as predictive of overall survival in this population. Additionally, we show low acute and late toxicity following SBRT in elderly patients.
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Affiliation(s)
- Philip A Sutera
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mark E Bernard
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Radiation Medicine, University of Kentucky, Lexington, KY, United States
| | - Hong Wang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Dwight E Heron
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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30
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Ng SP, Herman JM. Stereotactic Radiotherapy and Particle Therapy for Pancreatic Cancer. Cancers (Basel) 2018; 10:cancers10030075. [PMID: 29547526 PMCID: PMC5876650 DOI: 10.3390/cancers10030075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 03/10/2018] [Accepted: 03/14/2018] [Indexed: 01/19/2023] Open
Abstract
Pancreatic cancer is a devastating disease with poor survival outcomes. Recent studies have shown that the addition of radiotherapy to chemotherapy in the setting of locally advanced pancreatic cancer did not improve overall survival outcome. These studies commonly utilize conventional radiotherapy treatment fractionation and technique (typically 3-D conformal radiotherapy or intensity modulated radiotherapy). Although no clear benefit in overall survival was demonstrated in those studies, those who received radiotherapy did have a clear benefit in terms of local control. Therefore, there is increasing interest in exploring different techniques and/or modality of radiotherapy and dose/fractionation. Stereotactic radiotherapy, which employs a hypofractionated regimen, has the potential advantage of delivering a high dose of radiation to the tumor in a short period of time (typically over 5 days) with minimal dose to the surrounding normal structures. Particle therapy such as proton and carbon ion therapy are being explored as potential radiation modality that could cause greater biological damage to the tumor compared to photon treatment, with rapid dose falloff resulting in minimal to no dose to adjacent structures. This review will discuss the current literature and emerging roles of stereotactic radiotherapy and particle therapy in pancreatic cancer.
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Affiliation(s)
- Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
| | - Joseph M Herman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
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Sutera P, Bernard ME, Wang H, Bahary N, Burton S, Zeh H, Heron DE. Stereotactic Body Radiation Therapy for Locally Progressive and Recurrent Pancreatic Cancer after Prior Radiation. Front Oncol 2018; 8:52. [PMID: 29564223 PMCID: PMC5845878 DOI: 10.3389/fonc.2018.00052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 02/19/2018] [Indexed: 01/14/2023] Open
Abstract
Introduction Pancreatic adenocarcinoma is an aggressive malignancy that has consistently demonstrated poor outcomes despite aggressive treatments. Despite multimodal treatment, local disease progression and local recurrence are common. Management of recurrent or progressive pancreatic carcinomas proves a further challenge. In patients previously treated with radiation therapy, stereotactic body radiation therapy (SBRT) is a promising modality capable of delivering high dose to the tumor while limiting dose to critical structures. We aimed to determine the feasibility and tolerability of SBRT for recurrent or local pancreatic cancer in patients previously treated with external beam radiation therapy (EBRT). Materials and methods Patients treated with EBRT who developed recurrent or local pancreatic ductal adenocarcinoma treated with SBRT reirradiation at our institution, from 2004 to 2014 were reviewed. Our primary endpoints included overall survival (OS), local control, regional control, and late grade 3+ radiation toxicity. Endpoints were analyzed with the Kaplan-Meier method. The association of these survival endpoints with risk factors was studied with univariate Cox proportional hazards models. Results We identified 38 patients with recurrent/progressive pancreatic cancer treated with SBRT following prior radiation therapy. Prior radiation was delivered to a median dose of 50.4 Gy in 28 fractions. SBRT was delivered to a median dose of 24.5 Gy in 1-3 fractions. Surgical resection was performed on 55.3% of all patients. Within a median follow-up of 24.4 months (inter-quartile range, 14.9-32.7 months), the median OS from diagnosis for the entire cohort was 26.6 months (95% CI: 20.3-29.8) with 2-year OS of 53.0%. Median survival from SBRT was 9.7 months (95% CI, 5.5-13.8). The 2-year freedom from local progression and regional progression was 58 and 82%, respectively. For the entire cohort, 18.4 and 10.5% experienced late grade 2+ and grade 3+ toxicity, respectively. Conclusion This single institution retrospective review identified SBRT reirradiation to be a feasible and tolerable treatment strategy for patients with previous locally progressive or recurrent pancreatic adenocarcinoma.
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Affiliation(s)
- Philip Sutera
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mark E Bernard
- Department of Radiation Medicine, University of Kentucky, Lexington, KY, United States
| | - Hong Wang
- Department of Biostatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, United States
| | - Steven Burton
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Herbert Zeh
- Department of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Dwight E Heron
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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32
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Sutera PA, Bernard ME, Gill BS, Harper KK, Quan K, Bahary N, Burton SA, Zeh H, Heron DE. One- vs. Three-Fraction Pancreatic Stereotactic Body Radiation Therapy for Pancreatic Carcinoma: Single Institution Retrospective Review. Front Oncol 2017; 7:272. [PMID: 29184848 PMCID: PMC5694485 DOI: 10.3389/fonc.2017.00272] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/30/2017] [Indexed: 12/30/2022] Open
Abstract
Background/introduction Early reports of stereotactic body radiation therapy (SBRT) for pancreatic ductal adenocarcinoma (PDAC) used single fraction, but eventually shifted to multifraction regimens. We conducted a single institution review of our patients treated with single- or multifraction SBRT to determine whether any outcome differences existed. Methods and materials Patients treated with SBRT in any setting for PDAC at our facility were included, from 2004 to 2014. Overall survival (OS), local control (LC), regional control (RC), distant metastasis (DM), and late grade 3 or greater radiation toxicities from the time of SBRT were calculated using Kaplan–Meier estimation to either the date of last follow-up/death or local/regional/distant failure. Results We identified 289 patients (291 lesions) with pathologically confirmed PDAC. Median age was 69 (range, 33–90) years. Median gross tumor volume was 12.3 (8.6–21.3) cm3 and planning target volume 17.9 (12–27) cm3. Single fraction was used in 90 (30.9%) and multifraction in 201 (69.1%) lesions. At a median follow-up of 17.3 months (IQR 10.1–29.3 months), the median survival for the entire cohort 17.8 months with a 2-year OS of 35.3%. Univariate analysis showed multifraction schemes to have a higher 2-year OS 30.5% vs. 37.5% (p = 0.019), it did not hold significance on MVA. Multifractionation schemes were found to have a higher LC on MVA (HR = 0.53, 95% CI, 0.33–0.85, p = 0.009). At 2 years, late grade 3+ toxicity was 2.5%. Post-SBRT CA19-9 was found on MVA to be a prognostic factor for OS (HR = 1.01, 95% CI, 1.01–1.01, p = 0.009), RC (HR = 1.01, 95% CI 1.01–1.01, p = 0.02), and DM (HR = 1.01, 95% CI, 1.01–1.01, p = 0.001). Conclusion Our single institution retrospective review is the largest to date comparing single and multifraction SBRT and the first to show multifraction regimen SBRT to have a higher LC than single fractionation. Additionally, we show low rates of severe late toxicity with SBRT.
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Affiliation(s)
- Philip Anthony Sutera
- Department of Radiation Oncology, Hillman Cancer Center, Pittsburgh, PA, United States
| | - Mark E Bernard
- Department of Radiation Medicine, University of Kentucky, Lexington KY
| | - Beant S Gill
- Department of Radiation Oncology, Hillman Cancer Center, Pittsburgh, PA, United States
| | - Kamran K Harper
- Department of Radiation Oncology, Hillman Cancer Center, Pittsburgh, PA, United States
| | - Kimmen Quan
- Department of Radiation Oncology, Hillman Cancer Center, Pittsburgh, PA, United States
| | - Nathan Bahary
- Department of Medical Oncology, Hillman Cancer Center, Pittsburgh, PA, United States
| | - Steven A Burton
- Department of Radiation Oncology, Hillman Cancer Center, Pittsburgh, PA, United States
| | - Herbert Zeh
- Department of Surgical Oncology, Hillman Cancer Center, Pittsburgh, PA, United States
| | - Dwight E Heron
- Department of Radiation Oncology, Hillman Cancer Center, Pittsburgh, PA, United States
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Ryan JF, Groot VP, Rosati LM, Hacker-Prietz A, Narang AK, McNutt TR, Jackson JF, Le DT, Jaffee EM, Zheng L, Laheru DA, He J, Pawlik TM, Weiss MJ, Wolfgang CL, Herman JM. Stereotactic Body Radiation Therapy for Isolated Local Recurrence After Surgical Resection of Pancreatic Ductal Adenocarcinoma Appears to be Safe and Effective. Ann Surg Oncol 2017; 25:280-289. [PMID: 29063299 DOI: 10.1245/s10434-017-6134-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND A standardized treatment regimen for unresectable isolated local recurrence (ILR) of pancreatic ductal adenocarcinoma has not been established. This study evaluated the outcomes for patients with ILR who underwent stereotactic body radiation therapy (SBRT). METHODS The records of patients with ILR who underwent SBRT between 2010 and 2016 were retrospectively reviewed. Symptom palliation and treatment-related toxicity were recorded. Associations between patient or treatment characteristics and overall survival (OS), progression-free survival (PFS), and local progression-free survival (LPFS) were assessed. RESULTS The study identified 51 patients who received SBRT for ILR. Of the 51 patients, 26 (51%) had not received radiation therapy before SBRT. The median OS was 36 months after diagnosis. From the first day of SBRT, the median OS, PFS, and LPFS were respectively 16, 7, and 10 months. Patients with a recurrence-free interval of 9 months or longer after surgery had superior OS (P = 0.019). Maintenance chemotherapy after SBRT was associated with superior OS (P < 0.001) and LPFS (P = 0.027). In the multivariable analysis, poorly differentiated tumor grade [hazard ratio (HR) 11.274], positive surgical margins (HR 0.126), and reception of maintenance chemotherapy (HR 0.141) were independently associated with OS. Positive surgical margins (HR 0.255) and maintenance chemotherapy (HR 0.299) were associated with improved LPFS. Of 16 patients, 10 (63%) experienced abdominal pain relief after SBRT. Four patients (8%) experienced grade 3 gastrointestinal toxicity, and one patient experienced grade 4 gastrointestinal toxicity. CONCLUSIONS Use of SBRT for ILR improved pain for a majority of the patients with acceptable acute and late toxicity. The findings show that SBRT is a feasible treatment for select patients with ILR. For those who receive SBRT, maintenance chemotherapy should be considered.
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Affiliation(s)
- John F Ryan
- Department of Radiation Oncology & Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vincent P Groot
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lauren M Rosati
- Department of Radiation Oncology & Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy Hacker-Prietz
- Department of Radiation Oncology & Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol K Narang
- Department of Radiation Oncology & Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd R McNutt
- Department of Radiation Oncology & Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Juan F Jackson
- Department of Radiation Oncology & Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dung T Le
- Department of Radiation Oncology & Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth M Jaffee
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lei Zheng
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel A Laheru
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M Herman
- Department of Radiation Oncology & Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Director of Clinical Research, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1422, Houston, TX, USA.
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Boimel PJ, Berman AT, Li J, Apisarnthanarax S, Both S, Lelionis K, Larson GL, Teitelbaum U, Lukens JN, Ben-Josef E, Metz JM, Plastaras JP. Proton beam reirradiation for locally recurrent pancreatic adenocarcinoma. J Gastrointest Oncol 2017; 8:665-674. [PMID: 28890817 DOI: 10.21037/jgo.2017.03.04] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Local recurrence following definitive treatment for pancreatic adenocarcinoma is common and can be associated with significant morbidity and mortality. Retreatment options for these patients are limited. Proton beam reirradiation (PRT) may limit dose and toxicity to previously irradiated normal tissues in patients without evidence of metastatic disease. METHODS Between 8/2010-2/2015, 15 patients with isolated, locally-recurrent pancreatic cancer were treated with PRT. Acute toxicity was graded using CTC v 4.0 and defined as occurring within 90 days. Kaplan-Meier survival analysis was performed from the start of PRT. A log-rank test was used to compare survival with or without concurrent chemotherapy. RESULTS Median follow-up was 15.7 months [2-48] from the start of PRT. The median clinical target volume (CTV) was 71 cc [15-200]. Ten (67%) patients received concurrent chemotherapy. Median PRT dose was 59.4 Gy (37.5-59.4 Gy). The median time interval from the prior treatment course was 26.7 months (7-461.3). There was a rate of 13% acute ≥ grade 3 toxicities attributed to PRT. The median overall survival (OS) was 16.7 months (95% CI, 4.7-36) and OS at 1 year was 67%. The "in-field" failure free survival at one year was 87%. The locoregional progression free survival (LPFS) and distant metastasis free survival (DMFS) at 1 year was 72% and 64% respectively. Concurrent chemotherapy was associated with a higher median survival. CONCLUSIONS PRT was well tolerated, resulted in prolonged clinical outcomes compared to historical controls, and should be considered as a treatment option with concurrent chemotherapy in selected patients with locally-recurrent pancreatic cancer.
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Affiliation(s)
- Pamela J Boimel
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - Abigail T Berman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - Jonathan Li
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | | | - Stefan Both
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center, New York, USA
| | - Kristi Lelionis
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | | | - Ursina Teitelbaum
- Department of Hematology Oncology, University of Pennsylvania, Philadelphia, USA
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - Edgar Ben-Josef
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - James M Metz
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
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Rosati LM, Kumar R, Herman JM. Integration of Stereotactic Body Radiation Therapy into the Multidisciplinary Management of Pancreatic Cancer. Semin Radiat Oncol 2017; 27:256-267. [PMID: 28577833 DOI: 10.1016/j.semradonc.2017.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Although most patients with pancreatic cancer die of metastatic disease, an autopsy study showed that up to one-third of patients die of predominantly local disease. This patient population stands to benefit the most from radiation, surgery, or both. Unfortunately, however, single-agent chemotherapy has had minimal benefit in pancreatic cancer, and most patients progress distantly before receiving radiation therapy (RT). With the addition of multiagent chemotherapy, patients are living longer, and RT has emerged as an important modality in preventing local progression. Standard chemoradiation delivered over 5-6 weeks has been shown to improve local control, but this approach delays full-dose systemic therapy and increases toxicity when compared to chemotherapy alone. Stereotactic body RT (SBRT) delivered in 3-5 fractions can be used to accurately target the pancreatic tumor with small margins and limited acute treatment-related toxicity. Given the favorable toxicity profile, SBRT can easily be integrated with other therapies in all stages of pancreatic cancer. However, future studies are necessary to determine optimal dose or fractionation regimens and sequencing with targeted therapies and immunotherapy. The purpose of this review is to discuss our current understanding of SBRT in the multidisciplinary management of patients with pancreatic cancer and future implications.
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Affiliation(s)
- Lauren M Rosati
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rachit Kumar
- Division of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, AZ
| | - Joseph M Herman
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Stereotactic body radiation for pancreatic cancer: results of an international survey of practice patterns. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s13566-016-0267-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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